Inspection on 07/11/06 for Firlawn

This inspection was carried out on 7th November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Firlawn 04/11/08

Firlawn 07/11/07

Firlawn 09/06/06

Firlawn 09/12/05

Firlawn 03/05/05

Firlawn 11/11/04

Firlawn 28/04/04

Similar services:

Insight - Eastchurch

Southfields

Thorndene

Magenta

Seabourne House

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Dovedale Court

Lyncol House

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Firlawn Firlawn 402 Chessington Road West Ewell Surrey KT19 9EG Lead Inspector Helen Dickens Key Unannounced Inspection 7th November 2006 02:15 Firlawn DS0000013642.V318402.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Firlawn DS0000013642.V318402.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Firlawn DS0000013642.V318402.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Firlawn Address Firlawn 402 Chessington Road West Ewell Surrey KT19 9EG 020 8786 0514 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) EMAS Limited Company Mrs Jess Puah Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Firlawn DS0000013642.V318402.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th June 2006 Brief Description of the Service: Firlawn provides services for up to four service users. The property is a bungalow, which has a large lounge/dining room and small separate sitting area, single bedroom accommodation, kitchen, laundry and two bathrooms. One room has en-suite facilities and the three other bedrooms are sited near to the bathroom. The cost per resident per week is £884 and holidays, personal items, one-to-one support and complementary therapies are extra and charged separately. The bungalow is located off a main road, with parking for 4 cars. There is a large garden to the rear of the property which is shared by the companys sister home Oaklawn next door. Firlawn DS0000013642.V318402.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 3 hours and was the second key inspection to be undertaken in the Commission for Social Care Inspection year April 2006 to March 2007. Those Key Standards found to be satisfactory on the first visit were not re-examined during this inspection. The inspection was carried out by Mrs. Helen Dickens, Lead Inspector for the service. Mr. Charlie Puah, the Responsible Individual, represented the establishment. A tour of the premises took place and a number of files and documents, including staff recruitment files, quality assurance information, and health and safety certificates were examined as part of the inspection process. Only three residents live at Firlawn at the moment and two were at home and were spoken with during the afternoon. In addition one member of the bank staff was also interviewed. The inspector would like to thank the residents, staff and Responsible Individual for their time, assistance and hospitality. What the service does well: What has improved since the last inspection? All the Requirements made at the last inspection have either been partially or fully met and no Immediate Requirements were made during this visit. All communal hand-washing areas now have a paper towel roll and there are no cotton towels except each resident’s own. Firlawn DS0000013642.V318402.R01.S.doc Version 5.2 Page 6 Recruitment practices have also improved and those files examined were well organised and most of the information required by Schedule 2 of the Care Homes Regulations 2001 (as amended) including CRB and pova checks, was now on file. A number of other Requirements have been met including some health and safety matters, the need to review medication training, and to review staff to resident ratios to ensure there are sufficient staff to meet resident’s needs. The manager was also asked to review arrangements for quality assurance and for the induction of new staff and this work has been done. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Firlawn DS0000013642.V318402.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Firlawn DS0000013642.V318402.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Assessments for residents are good and therefore the needs and aspirations of residents are properly identified and are more likely to be met. EVIDENCE: From June 06 Original assessments on residents showed that there was a good overview of health and personal care needs, and health and social care professionals had been involved in various aspects of these assessments. Health needs had been particularly well noted and the resident’s care plans and risk assessments had been drawn up using these documents. There was evidence of social and religious needs being included, and resident’s families had had input into these assessments. The home’s policy on admission included pre-admission assessment activity with prospective residents, for example visits to the home and overnight stays, prior to admission. This Standard was not re-assessed on this visit. Firlawn DS0000013642.V318402.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care planning at this home is well done; residents have some input into decision-making and are supported to take risks in their everyday lives. EVIDENCE: From June 2006 – Care plans examined contained a good overview of resident’s needs and how these would be met. Specialist advice had been sought on relevant areas such as activities of daily living (from the occupational therapist) and eating (the speech therapist reported on the high risk of choking and how to avoid this risk). The weekly activities plan was on each resident’s file, together with instructions on how to minimise risk and manage certain behaviour patterns. Firlawn DS0000013642.V318402.R01.S.doc Version 5.2 Page 10 Residents were assisted to make limited decisions and the manager said this was commensurate with their capabilities. For example their recent holiday had been chosen because residents like the seaside and they were shown some brochures to help them to choose. Another example given by the manager was that residents get up in their own time, and choose when they would like something to eat or drink. The home had contacted advocacy services of behalf of residents and family members were involved with each resident. The registered manager has started work on introducing personal support plans for all residents at this home. These Standards were not re-assessed during this visit. Firlawn DS0000013642.V318402.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are assisted to take part in activities, and participate in the local community. Family relationships are encouraged and resident’s dietary needs well met. EVIDENCE: From June 2006 – Resident’s have a weekly plan of activities and this includes day care where there is a specific evaluation of goals to promote independence. Residents particularly enjoyed music therapy and aroma therapy, but other opportunities for eating out and to be sociable were also mentioned. One resident who does not like company is supported to take part in activities where they do not have to mix with others. Firlawn DS0000013642.V318402.R01.S.doc Version 5.2 Page 12 Residents have access to local community facilities and like to eat out, go for picnics, and walk in the park. The residents do not use public transport as the home has its own vehicle. The manager said they have a good relationship with their neighbours. Family members are made welcome at Firlawn and visit the home regularly; the manager said visiting times are flexible. Relatives are also invited to parties and barbecues at the home. A number of letters on file suggest that family members are happy with the care given to residents. Resident’s dietary needs are given priority as are risks to do with choking which is a significant concern at this home. Foods which represent a particular choking hazard are well documented and assessments from professionals give clear guidance to staff about what to avoid. Staff sit with residents during mealtimes. The menus were sampled and these are drawn up by staff with limited involvement from residents. The manager said staff have ascertained what residents like to eat and they have then planned the menus accordingly. Residents weights are monitored and their files showed they had been weighed every month since they first moved into the home. These Standards were not re-assessed during this visit. Firlawn DS0000013642.V318402.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents receive personal support in the way they prefer, and their emotional and health care needs are met. The administration of medication is well organised and further work has been done to meet this Standard in full. EVIDENCE: From June 2006 inspection – Care plans identify the help and support needed by residents with activities of daily living, and specialist assessments have been obtained. Care plans are reviewed on an annual basis so there is an up to date record of how resident’s needs have changed. Residents choose when to get up and go to bed and assistance with personal hygiene is available. This home has worked very hard to ascertain and mange the health needs of residents. Health needs and the support needed by each resident are very well Firlawn DS0000013642.V318402.R01.S.doc Version 5.2 Page 14 documented and the home ensure any changes are monitored and reviewed by the appropriate community professional. Clear instructions are available to staff to assist them in supporting residents in relation to their health needs. These Standards were not re-assessed during this visit. In June 2006 it was noted that the administration of medication is well organised at this home. Medication is securely stored, there were no excess medicines in the home, and medication administration records were well kept. During this inspection in November 2006 improvements have been made including all staff up-dating their medication training with an external trainer who specialises in this field. The community pharmacist’s advice has been sought and an inspection carried out at this home. The home was also asked to review their arrangements for ‘as required’ medication and this has been done. It was also noted that there is a list of staff signatures showing which staff could give medication. Firlawn DS0000013642.V318402.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s views are listened to and they are protected from abuse. EVIDENCE: From June 2006 – There is a complaints procedure at the home and it is translated into three different formats to suit resident’s needs. It contains details of the CSCI address and time limits for taking action. The complaints log was sampled and there have been no complaints since the last inspection. The home has received a number of commendations during this period. This Standard was not re-assessed on this visit. The home has a policy on the protection of vulnerable adults and the staff spoken to were clear about their responsibilities. The latest version of the Surrey multi-agency procedures for the protection of vulnerable adults is available in the home. Induction training checklists confirm that this subject is covered for all new recruits and all staff have received up-dated training from an external trainer on this issue. Firlawn DS0000013642.V318402.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Firlawn provides a very homely and comfortable environment for residents, and the standard of hygiene and cleanliness is good. EVIDENCE: From June 2006 inspection On arrival at this home the residents were away on holiday and due to return later in the day. The home was fragrant, and clean and tidy throughout. Firlawn offers a very homely environment which is kept well decorated and well maintained for the benefit of residents. Furnishings and fittings are domestic in character and there are many ‘homely’ touches including plenty of well cared for plants, two fish tanks and a variety of pictures around the home. There is a large living/dining room which leads out Firlawn DS0000013642.V318402.R01.S.doc Version 5.2 Page 17 onto the garden, and an extra small room for residents who wish to watch TV. The home and garden are fully accessible for residents. The minor decorative issues and the laundry room were re-assessed during this visit in November 06. Minor decorative matters which needed attention in June 2006 have all been dealt with including a crack in the ceiling/wall join in the front bedroom which has been filled and repainted. The responsible individual said that other cracks which had appeared in the new bedroom will also be dealt with. The laundry room was also clean and tidy and a large commercial machine provides for washing at high temperatures. Systems are in place to control the spread of infection. Instructions for staff on the proper care of resident’s laundry was posted in the laundry room itself. The room is locked with a small bolt and no washing liquids/powders were left out. Firlawn DS0000013642.V318402.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35 and 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are competent to carry out their roles. Recruitment practices have improved though more work needs to be done to meet this Standard in full. Resident’s benefit from the staff induction, training and supervision arrangements which have also improved. EVIDENCE: From June 2006 – Staff interacted well with residents and were seen to be approachable and motivated. Out of the six permanent staff, two are registered nurses and one has an NVQ2 in care. Another has just completed an HND in health and care. The member of staff interviewed was enthusiastic about working with these particular residents and complimentary about the training and support offered by the manager and responsible individual. The manager said this staff Firlawn DS0000013642.V318402.R01.S.doc Version 5.2 Page 19 member had not done any external training yet as she was completing her HND. Service users were being adequately supported on the day of the inspection but the inspector expressed concern about the practice of sometimes having one member of staff on duty in the home. The registered manager was asked to review this. At the November 2006 inspection the responsible individual said that the Residential Forum matrix had been used and staff numbers had been reviewed and whilst there were only two residents at home during the day (a third was out at day care), one staff member was deemed to be sufficient for short periods. Now that the variation for the extra room has been granted, the home will be looking to admit a fourth resident. The responsible individual said that there will then be two members of staff on duty during the day. At the November 2006 inspection three staff recruitment files were examined and a number of improvements were noted. Files were kept in good order and all staff had properly completed application forms and CRB and pova checks in place. One staff member’s reference from their last care employer could not be found on the day of the inspection as the manager was not on duty; a copy of the verbal reference was posted to CSCI on the following day. Two staff members had their second reference from work colleagues/friends and this is not recommended. This work has been part of an ongoing project to up-date all recruitment files and it should now be concluded in a timely fashion. Induction records were on file and had been signed off by the manager. One member of staff interviewed outlined her induction and training since she had come to work at Firlawn 4 months ago and this was found to be satisfactory. The responsible individual was asked to consult the CRB website for guidance with regard to the proper storage/destruction/ and timescale for re-applying for CRBs. If a list of CRB numbers is to be kept, this should also confirm whether a pova check was carried out and the results. There is evidence of staff training at this home and training certificates are kept on staff files. The review of training arrangements recommended at the last inspection has been carried out. All staff who give medication have now had up-dated medication training provided by a specialist medication training company, and the package has been purchased so that the owners will be able to up-date staff training themselves. All staff have also had external training on protecting vulnerable adults and the staff member interviewed was knowledgeable on her responsibilities even though she had missed the training due to illness and was now booked onto another course. Staff have an induction course and the three files sampled showed these had been signed off by the manager. The staff member interviewed confirmed she had completed her induction and outlined the subjects she had covered. Firlawn DS0000013642.V318402.R01.S.doc Version 5.2 Page 20 There was evidence from staff files that the frequency of formal staff supervision sessions had increased and of those files examined, all were on course to receive the recommended 6 sessions in twelve months. Firlawn DS0000013642.V318402.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s benefit from a well run home. Quality assurance processes continue to improve and the health, safety and welfare of residents are promoted at Firlawn. EVIDENCE: From June 2006 The registered manager is a trained nurse (RMN, RMNH) with a Diploma in Community Nursing. She has had twenty six years experience of managing and an NVQ4 qualification in management. Some of the management Firlawn DS0000013642.V318402.R01.S.doc Version 5.2 Page 22 responsibilities (e.g. the budget) are shared with the responsible individual, Mr. Puah. The registered manager does refresher training herself from time to time and did health and safety training two years ago and first aid three years ago. She also attended the specialist medication training arranged since the last inspection. This Standard was not re-assessed on this visit. It was noted at the June 2006 inspection that there are some quality assurance systems in place including early work on an annual development plan and a staff development plan which were started last year. There is a monthly health and safety audit and a fire safety audit including a monthly fire drill. There is a policy on quality assurance but the home is not currently following it closely. Also, the main contributors are Mr. and Mrs. Puah, and the manager of their third home; quality assurance work needs to involve other stakeholders, especially residents and staff. There are some comments on file from relatives but these are largely contained in thank you letters, rather than gathered systematically as part of an annual questionnaire for example. The responsible individual should review the current arrangements for quality assurance and ensure they are meeting all aspects of Standard 39. At the November 2006 inspection it was noted that further work had been done on the issues noted above but the annual development plan still needs to be drawn up with regard to all the items listed in Standard 39. A further Requirement will be made in this regard. At the June 2006 inspection it was noted that health and safety is taken seriously at this home and a number of measures are already in place, including the monthly health and safety audit. Risk assessments identified particular areas of concern and there is clear guidance for staff on preventative measures. Areas needing review at that time included legionella safety and this has since been reviewed and the home has had a legionella safety test carried out. They are currently purchasing a set of policies, including legionella safety, and they will implement this as soon as possible. At the June 2006 inspection it was noted that the home did not have radiator covers in place and the radiators had adjustable thermostats. The radiators were not on whilst the inspection was being carried out as the weather was very warm. However, the responsible individual was asked to carry out a risk assessment on the absence of radiator covers and then take action as suggested by that assessment. At this inspection in November 2006 the registered manager had carried out a risk assessment and this suggested that some radiators needed to have covers fitted. Of those which have been fitted, not all have had the top added which would complete the stylish look – it was also noted that those with and without Firlawn DS0000013642.V318402.R01.S.doc Version 5.2 Page 23 a top have sharp corners and the responsible individual said he would remedy this. This has been an ongoing project over the summer and now needs to be completed in a timely fashion. A risk assessment for the toiletries left in the bathrooms should also be carried out – the responsible individual said that none of the present residents would be at risk but there is no documented risk assessment on file and he agreed to ensure this was done. At the June 2006 inspection it was noted that the kitchen was generally very clean and tidy and there were instructions for staff on the cleaning regimes for worktops etc, and on the use of the colour coded chopping boards. The fire extinguisher on the wall had recently been serviced and the fridge temperature was with recommended limits. This was still the case during the November 2006 inspection. Firlawn DS0000013642.V318402.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 x LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 X 2 X X 2 x Firlawn DS0000013642.V318402.R01.S.doc Version 5.2 Page 25 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA34 Regulation 19(1)(a)(b)(c) Schedule 2 Requirement The responsible individual must not employ a person to work at the care home unless he has obtained the information and documents specified in paragraph 1-9 of Schedule 2 of The Care Homes Regulations 2001 as amended by The Care Standards Act 2000 (Establishments and Agencies) (Miscellaneous Amendments) Regulations 2004. This applies to all existing members of staff who have started employment at this home since July 2004. (Partially met from 09/07/06). Timescale for action 07/12/06 2. YA39 3. Firlawn YA42 24(1)(a)(b)24(2) The responsible individual 07/12/06 must review the current arrangements for quality assurance and ensure the home is meeting all aspects of Standard 39, including an annual development plan. (Partially met from 09/08/06) 13(4)(a)(c) The responsible individual 07/12/06 DS0000013642.V318402.R01.S.doc Version 5.2 Page 26 must continue and conclude the project to install radiator covers on those radiators risk assessed as needing them. Attention must be given to those radiator covers with sharp corners as discussed during the inspection. (Partially met from 10/06/06) 4. YA42 13(4)(a)(c) The responsible individual 08/11/06 must have a documented risk assessment on file concerning the toiletries and liquids which belong to residents and are kept in the main bathroom. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA34 Good Practice Recommendations The responsible individual should consult the CRB website for guidance on storing, destroying, and the recommended frequency of re-applying for CRBs. Firlawn DS0000013642.V318402.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Firlawn DS0000013642.V318402.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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